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Arrigo M, Davison B, Edwards C, Adamo M, Ambrosy AP, Barros M, Biegus J, Celutkiene J, Čerlinskaitė-Bajorė K, Chioncel O, Cohen-Solal A, Damasceno A, Diaz R, Filippatos G, Gayat E, Kimmoun A, Lam CSP, Metra M, Novosadova M, Pagnesi M, Pang PS, Ponikowski P, Saidu H, Sliwa K, Takagi K, Ter Maaten JM, Tomasoni D, Voors AA, Cotter G, Mebazaa A. Characteristics, treatment, and outcomes of early vs. late enrollees of the STRONG-HF trial. Am Heart J 2024; 274:119-129. [PMID: 38740532 DOI: 10.1016/j.ahj.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/25/2024] [Accepted: 04/27/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND The STRONG-HF trial showed that high-intensity care (HIC) consisting of rapid up-titration of guideline-directed medical therapy (GDMT) and close follow-up reduced all-cause death or heart failure (HF) readmission at 180 days compared to usual care (UC). We hypothesized that significant differences in patient characteristics, management, and outcomes over the enrolment period may exist. METHODS Two groups of the 1,078 patients enrolled in STRONG-HF were created according to the order of enrolment within center. The early group consisted of the first 10 patients enrolled at each center (N = 342) and the late group consisted of the following patients (N = 736). RESULTS Late enrollees were younger, had more frequently reduced ejection fraction, slightly lower NT-proBNP and creatinine levels compared with early enrollees. The primary outcome occurred less frequently in early compared to late enrollees (15% vs. 21%, aHR 0.65, 95% CI 0.42-0.99, P = .044). No treatment-by-enrolment interaction was seen in respect to the average percentage of optimal dose of GDMT after randomization, which was consistently higher in early and late patients randomized to HIC compared to UC. The higher use of renin-angiotensin-inhibitors in the HIC arm was more pronounced in the late enrollees both after randomization (interaction-P = .013) and at 90 days (interaction-P < .001). No interaction was observed for safety events. Patients randomized late to UC displayed a trend toward more severe outcomes (26% vs. 16%, P = .10), but the efficacy of HIC showed no interaction with the enrolment group (aHR 0.77, 95% CI 0.35-1.67 in early and 0.58, 95% CI 0.40-0.83 in late enrollees, adjusted interaction-P = .51) with similar outcomes in the HIC arm in late and early enrollees (16% vs. 13%, P = .73). CONCLUSIONS Late enrollees have different clinical characteristics and higher event rates compared to early enrollees. GDMT implementation in the HIC arm robustly achieved similar doses with consistent efficacy in early and late enrollees, mitigating the higher risk of adverse outcome in late enrollees. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03412201.
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Affiliation(s)
- Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland.
| | - Beth Davison
- Université Paris Cité, Paris, France; Heart Initiative, Durham, NC
| | | | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof. C.C.Iliescu", University of Medicine "Carol Davila", Bucharest, Romania
| | - Alain Cohen-Solal
- Université Paris Cité, Paris, France; Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Etienne Gayat
- Heart Initiative, Durham, NC; Momentum Research, Inc., Durham, NC
| | - Antoine Kimmoun
- Université de Lorraine, Nancy; INSERM, Défaillance Circulatoire Aigue et Chronique; Service de Médecine Intensive et Réanimation Brabois, 54511 Vandœuvre-lès-Nancy, France
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Hadiza Saidu
- Department of Medicine, Murtala Muhammed Specialist Hospital / Bayero University Kano, Kano, Nigeria
| | - Karen Sliwa
- Cape Heart Institute, Division of Cardiology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | | | - Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, Netherlands
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, Netherlands
| | - Gad Cotter
- Université Paris Cité, Paris, France; Heart Initiative, Durham, NC
| | - Alexandre Mebazaa
- Université Paris Cité, Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
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Buttar C, Alai H, Matanes FN, Cassidy MM, Stencel J, Le Jemtel TH, Buttar C. Full Decongestion in Acute Heart Failure Therapy. Am J Med Sci 2024:S0002-9629(24)01273-4. [PMID: 38880301 DOI: 10.1016/j.amjms.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 06/07/2024] [Accepted: 06/07/2024] [Indexed: 06/18/2024]
Abstract
Incomplete decongestion is the main cause of readmission in the early post-discharge period of a hospitalization for acute heart failure. Recent heart failure guidelines have highlighted initiation and rapid up-titration of quadruple therapy with angiotensin receptor neprilysin inhibitor, beta adrenergic receptor blocker, mineralocorticoid receptor antagonist, and sodium glucose cotransporter 2 inhibitor to prevent hospitalizations for heart failure with reduced ejection fraction. However, full decongestion remains the foremost therapeutic goal of hospitalization for heart failure. While early addition of sodium glucose cotransporter 2 inhibitors and mineralocorticoid receptor antagonists may be helpful, the value of the other therapeutics comes after decongestion is complete.
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Affiliation(s)
- Chandan Buttar
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119.
| | - Hamid Alai
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119.
| | - Faris N Matanes
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119.
| | - Mark M Cassidy
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119.
| | - Jason Stencel
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119.
| | - Thierry H Le Jemtel
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119.
| | - Chandan Buttar
- Department of Cardiology, Tulane University Medical Center, New Orleans, LA, 1415 Tulane Ave, New Orleans, LA 70112.
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3
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Veltmann C, Duncker D, Doering M, Gummadi S, Robertson M, Wittlinger T, Colley BJ, Perings C, Jonsson O, Bauersachs J, Sanchez R, Maier LS. Therapy duration and improvement of ventricular function in de novo heart failure: the Heart Failure Optimization study. Eur Heart J 2024:ehae334. [PMID: 38864173 DOI: 10.1093/eurheartj/ehae334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 04/30/2024] [Accepted: 05/15/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND AND AIMS In patients with de novo heart failure with reduced ejection fraction (HFrEF), improvement of left ventricular ejection fraction (LVEF) is expected to occur when started on guideline-recommended medical therapy. However, improvement may not be completed within 90 days. METHODS Patients with HFrEF and LVEF ≤ 35% prescribed a wearable cardioverter-defibrillator between 2017 and 2022 from 68 sites were enrolled, starting with a registry phase for 3 months and followed by a study phase up to 1 year. The primary endpoints were LVEF improvement > 35% between Days 90 and 180 following guideline-recommended medical therapy initiation and the percentage of target dose reached at Days 90 and 180. RESULTS A total of 598 patients with de novo HFrEF [59 years (interquartile range 51-68), 27% female] entered the study phase. During the first 180 days, a significant increase in dosage of beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists was observed (P < .001). At Day 90, 46% [95% confidence interval (CI) 41%-50%] of study phase patients had LVEF improvement > 35%; 46% (95% CI 40%-52%) of those with persistently low LVEF at Day 90 had LVEF improvement > 35% by Day 180, increasing the total rate of improvement > 35% to 68% (95% CI 63%-72%). In 392 patients followed for 360 days, improvement > 35% was observed in 77% (95% CI 72%-81%) of the patients. Until Day 90, sustained ventricular tachyarrhythmias were observed in 24 wearable cardioverter-defibrillator carriers (1.8%). After 90 days, no sustained ventricular tachyarrhythmia occurred in wearable cardioverter-defibrillator carriers. CONCLUSIONS Continuous optimization of guideline-recommended medical therapy for at least 180 days in HFrEF is associated with additional LVEF improvement > 35%, allowing for better decision-making regarding preventive implantable cardioverter-defibrillator therapy.
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Affiliation(s)
- Christian Veltmann
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
- Heart Center Bremen, Electrophysiology Bremen, Senator-Wessling-Str. 1, 28277 Bremen, Germany
| | - David Duncker
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Michael Doering
- Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Siva Gummadi
- Department of Cardiology, CVI of Central Florida, Ocala, FL, USA
| | | | - Thomas Wittlinger
- Department of Cardiology, Asklepios Harzklinik Goslar, Goslar, Germany
| | - Byron J Colley
- Department of Cardiology, Jackson Heart Clinic, Jackson, MS, USA
| | - Christian Perings
- Department of Cardiology, Katholisches Klinikum Luenen, Luenen, Germany
| | - Orvar Jonsson
- Department of Cardiology, Sanford Cardiovascular Institute, Sioux Falls, SD, USA
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Robert Sanchez
- Department of Cardiology, HCA Florida Heart Institute, St. Petersburg, FL, USA
| | - Lars S Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Spadafora L, Bernardi M, Sarto G, Simeone B, Forte M, D'Ambrosio L, Betti M, D'Amico A, Cammisotto V, Carnevale R, Bartimoccia S, Sabouret P, Zoccai GB, Frati G, Valenti V, Sciarretta S, Rocco E. Towards the Fifth Pillar for the Treatment of Heart Failure with Reduced Ejection Fraction: Vericiguat in Older and Complex Patients. Am J Cardiovasc Drugs 2024:10.1007/s40256-024-00652-6. [PMID: 38856965 DOI: 10.1007/s40256-024-00652-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 06/11/2024]
Abstract
Heart failure with reduced ejection fraction (HFrEF) represents an emerging epidemic, particularly affecting frail, older, and multimorbid patients. Current therapy for the management of HFrEF includes four different classes of disease-modifying drugs, commonly referred to as 'four pillars', which target the neurohormonal system that is overactivated in HF and contributes to its progression. These classes of drugs include β-blockers, inhibitors of the renin-angiotensin-aldosterone system, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter-2 (SGLT2) inhibitors. Unfortunately, these agents cannot be administered as frequently as needed to older patients because of poor tolerability and comorbidities. In addition, although these drugs have dramatically increased the survival expectations of patients with HF, their residual risk of rehospitalization and death at 5 years remains considerable. Vericiguat, a soluble guanylate cyclase (sGC) stimulator, was reported to exert beneficial effects in patients with worsening HF, including older subjects, reducing the rate of both hospitalizations and deaths, with limited adverse effects and drug interaction. In this narrative review, we present the current state of art on vericiguat, with a particular focus on elderly and frail patients.
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Affiliation(s)
- Luigi Spadafora
- Department of Clinical Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.
| | - Marco Bernardi
- Department of Clinical Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Gianmarco Sarto
- Cardiology Division, ICOT Istituto "Marco Pasquali" University Hospital, Latina, Italy
| | - Beatrice Simeone
- Cardiology Division, ICOT Istituto "Marco Pasquali" University Hospital, Latina, Italy
| | | | - Luca D'Ambrosio
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Matteo Betti
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Alessandra D'Amico
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Vittoria Cammisotto
- Department of Clinical Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Carnevale
- IRCCS Neuromed, Pozzilli, Italy
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Simona Bartimoccia
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Pierre Sabouret
- Heart Institute and Action Group, Pitié-Salpétrière, Sorbonne University, Paris, France
- National College of French Cardiologists, Paris, France
| | - Giuseppe Biondi Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
- Cardiology Unit, Santa Maria Goretti Hospital, Latina, Italy
| | - Giacomo Frati
- IRCCS Neuromed, Pozzilli, Italy
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Valentina Valenti
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Sebastiano Sciarretta
- IRCCS Neuromed, Pozzilli, Italy
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
| | - Erica Rocco
- Cardiology Division, ICOT Istituto "Marco Pasquali" University Hospital, Latina, Italy
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5
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Uemura Y, Shibata R, Sawada K, Ishikawa S, Takemoto K, Murohara T, Watarai M. Prognostic impact of polypharmacy and discharge medications in octogenarians and nonagenarian patients with acute heart failure. Heart Vessels 2024; 39:514-523. [PMID: 38386100 DOI: 10.1007/s00380-024-02366-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/18/2024] [Indexed: 02/23/2024]
Abstract
With the increasing frequency of heart failure (HF) in elderly patients, polypharmacy has become a major concern owing to its adverse outcomes. However, reports on the clinical impact of polypharmacy and discharge medications in hospitalized super-aged patients with acute HF are rare. Data from 682 patients aged 80 years or older, hospitalized for treating acute HF, were analyzed. We recorded the number of medications at discharge and classified them into three groups: HF, non-HF cardiovascular, and non-cardiovascular medications. We investigated the correlation of polypharmacy, defined as daily administration of 10 or more medications at discharge, and the use of discharge medications with post-discharge prognosis. Polypharmacy was recorded in 24.3% of enrolled patients. Polypharmacy was not an independent predictor of all-cause mortality, the incidence of cardiac-related death, or HF-associated rehospitalization; however, the number of non-cardiovascular medications, multiple usage of potentially inappropriate medications, use of mineralocorticoid receptor antagonists, and doses of loop diuretics were associated with poor prognosis. Polypharmacy was significantly associated with higher mortality in patients with Barthel index ≥ 60 at discharge; hence, physical function at discharge was useful for the stratification of prognostic impacts of polypharmacy. The current study demonstrated that polypharmacy was not essentially associated with poor prognosis in super-aged patients with acute HF. Appropriate medications that consider the patient's physical function, rather than polypharmacy itself, are important for the management of HF.
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Affiliation(s)
- Yusuke Uemura
- Cardiovascular Center, Anjo Kosei Hospital, 28 Higashi-Hirokute, Anjo, 446-8602, Japan.
| | - Rei Shibata
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Shinji Ishikawa
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenji Takemoto
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Watarai
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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6
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Mentias A, Keshvani N, Sumarsono A, Desai R, Khan MS, Menon V, Hsich E, Bress AP, Jacobs J, Vasan RS, Fonarow GC, Pandey A. Patterns, Prognostic Implications, and Rural-Urban Disparities in Optimal GDMT Following HFrEF Diagnosis Among Medicare Beneficiaries. JACC. HEART FAILURE 2024; 12:1044-1055. [PMID: 37943222 DOI: 10.1016/j.jchf.2023.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Patterns and disparities in guideline-directed medical therapy (GDMT) uptake for heart failure with reduced ejection fraction (HFrEF) across rural vs urban regions are not well described. OBJECTIVES This study aims to evaluate patterns, prognostic implications, and rural-urban differences in GDMT use among Medicare beneficiaries following new-onset HFrEF. METHODS Patients with a diagnosis of new-onset HFrEF in a 5% Medicare sample with available data for Part D medication use were identified from January 2015 through December 2020. The primary exposure was residence in rural vs urban zip codes. Optimal triple GDMT was defined as ≥50% of the target daily dose of beta-blockers, ≥50% of the target daily dose of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker or any dose of sacubitril/valsartan, and any dose of mineralocorticoid receptor antagonist. The association between the achievement of optimal GDMT over time following new-onset HFrEF diagnosis and risk of all-cause mortality and subsequent HF hospitalization was also evaluated using adjusted Cox models. The association between living in rural vs urban location and time to optimal GDMT achievement over a 12-month follow-up was assessed using cumulative incidence curves and adjusted Fine-Gray subdistribution hazard models. RESULTS A total of 41,296 patients (age: 76.7 years; 15.0% Black; 27.6% rural) were included. Optimal GDMT use over the 12-month follow-up was low, with 22.5% initiated on any dose of triple GDMT and 9.1% on optimal GDMT doses. Optimal GDMT on follow-up was significantly associated with a lower risk of death (HR: 0.89 [95% CI: 0.85-0.94]; P < 0.001) and subsequent HF hospitalization (HR: 0.93 [95% CI: 0.87-0.98]; P = 0.02). Optimal GDMT use at 12 months was significantly lower among patients living in rural (vs urban) areas (8.4% vs 9.3%; P = 0.02). In adjusted analysis, living in rural (vs urban) locations was associated with a significantly lower probability of achieving optimal GDMT (HR: 0.92 [95% CI: 0.86-0.98]; P = 0.01 Differences in optimal GDMT use following HFrEF diagnosis accounted for 16% of excess mortality risk among patients living in rural (vs urban) areas. CONCLUSIONS Use of optimal GDMT following new-onset HFrEF diagnosis is low, with substantially lower use noted among patients living in rural vs urban locations. Suboptimal GDMT use following new-onset HFrEF was associated with an increased risk of mortality and subsequent HF hospitalization.
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Affiliation(s)
- Amgad Mentias
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Andrew Sumarsono
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | - Venu Menon
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eileen Hsich
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adam P Bress
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Joshua Jacobs
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Ramachandran S Vasan
- School of Public Health, Department of Population Health, and Division of Cardiology, Long School of Medicine, University of Texas San Antonio, San Antonio, Texas, USA
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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7
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Ruzzolini M, Giallauria F, Fattirolli F, Venturini E, Maranta F, Mureddu GF, Calisi P, Griffo R, Vigorito C, Faggiano P, Ambrosetti M, Masarone D. Cardiac contractility modulation in patients with heart failure: The added value of cardiac rehabilitation in identification, management, and follow-up. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 21:200284. [PMID: 38846680 PMCID: PMC11152971 DOI: 10.1016/j.ijcrp.2024.200284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 04/13/2024] [Accepted: 05/07/2024] [Indexed: 06/09/2024]
Affiliation(s)
- Matteo Ruzzolini
- Department of Cardiology, Isola Tiberina-Gemelli Isola Hospital, Rome, Italy, Italy
| | - Francesco Giallauria
- Department of Translational Medical Sciences, "Federico II" University of Naples, Italy
| | | | | | - Francesco Maranta
- Department of Cardiac Rehabilitation, IRCCS San Raffaele Hspital, Milan, Italy
| | | | | | - Raffaele Griffo
- Italian Alliance for Cardiovascular Rehabilitation and Prevention (ITACARE-P), Italy
| | - Carlo Vigorito
- Department of Translational Medical Sciences, "Federico II" University of Naples, Italy
| | - Pompilio Faggiano
- Cardiovascular Department, Fondazione Poliambulanza, 25100, Brescia, Italy
| | - Marco Ambrosetti
- Department of Cardiac Rehabilitation, ASST Crema, Rivolta d’Adda, Italy
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8
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Eberly LA, Tennison A, Mays D, Hsu CY, Yang CT, Benally E, Beyuka H, Feliciano B, Norman CJ, Brueckner MY, Bowannie C, Schwartz DR, Lindsey E, Friedman S, Ketner E, Detsoi-Smiley P, Shyr Y, Shin S, Merino M. Telephone-Based Guideline-Directed Medical Therapy Optimization in Navajo Nation: The Hózhó Randomized Clinical Trial. JAMA Intern Med 2024; 184:681-690. [PMID: 38583185 PMCID: PMC11000136 DOI: 10.1001/jamainternmed.2024.1523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/20/2024] [Indexed: 04/09/2024]
Abstract
Importance Underutilization of guideline-directed medical therapy for heart failure with reduced ejection fraction is a major cause of poor outcomes. For many American Indian patients receiving care through the Indian Health Service, access to care, especially cardiology care, is limited, contributing to poor uptake of recommended therapy. Objective To examine whether a telehealth model in which guideline-directed medical therapy is initiated and titrated over the phone with remote telemonitoring using a home blood pressure cuff improves guideline-directed medical therapy use (eg, drug classes and dosage) in patients with heart failure with reduced ejection fraction in Navajo Nation. Design, Setting, and Participants The Heart Failure Optimization at Home to Improve Outcomes (Hózhó) randomized clinical trial was a stepped-wedge, pragmatic comparative effectiveness trial conducted from February to August 2023. Patients 18 years and older with a diagnosis of heart failure with reduced ejection fraction receiving care at 2 Indian Health Service facilities in rural Navajo Nation (defined as having primary care physician with 1 clinical visit and 1 prescription filled in the last 12 months) were enrolled. Patients were randomized to the telehealth care model or usual care in a stepped-wedge fashion, with 5 time points (30-day intervals) until all patients crossed over into the intervention. Data analyses were completed in January 2024. Intervention A phone-based telehealth model in which guideline-directed medical therapy is initiated and titrated at home, using remote telemonitoring with a home blood pressure cuff. Main Outcomes and Measures The primary outcome was an increase in the number of guideline-directed classes of drugs filled from the pharmacy at 30 days postrandomization. Results Of 103 enrolled American Indian patients, 42 (40.8%) were female, and the median (IQR) age was 65 (53-77) years. The median (IQR) left ventricular ejection fraction was 32% (24%-36%). The primary outcome occurred significantly more in the intervention group (66.2% vs 13.1%), thus increasing uptake of guideline-directed classes of drugs by 53% (odds ratio, 12.99; 95% CI, 6.87-24.53; P < .001). The number of patients needed to receive the telehealth intervention to result in an increase of guideline-directed drug classes was 1.88. Conclusions and Relevance In this heart failure trial in Navajo Nation, a telephone-based strategy of remote initiation and titration for outpatients with heart failure with reduced ejection fraction led to improved rates of guideline-directed medical therapy at 30 days compared with usual care. This low-cost strategy could be expanded to other rural settings where access to care is limited. Trial Registration ClinicalTrials.gov Identifier: NCT05792085.
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Affiliation(s)
- Lauren A. Eberly
- Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia
- Penn Cardiovascular Center for Health Equity and Social Justice, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ada Tennison
- Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico
| | - Daniel Mays
- Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico
| | - Chih-Yuan Hsu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chih-Ting Yang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ernest Benally
- Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico
| | - Harriett Beyuka
- Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico
| | - Benjamin Feliciano
- Office of Quality, Division of Innovations and Improvement, Indian Health Service Headquarters, Rockville, Maryland
| | - C. Jane Norman
- Office of Quality, Division of Innovations and Improvement, Indian Health Service Headquarters, Rockville, Maryland
| | | | - Clybert Bowannie
- Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico
| | - Daniel R. Schwartz
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Erica Lindsey
- Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico
| | - Stephen Friedman
- Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico
| | - Elizabeth Ketner
- Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico
| | | | - Yu Shyr
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sonya Shin
- Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Maricruz Merino
- Gallup Indian Medical Center, Indian Health Service, Gallup, New Mexico
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9
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Baran DA, Snipelisky D. Hard Work and Talent in the Battle Against Heart Failure. JACC. HEART FAILURE 2024; 12:1071-1072. [PMID: 38839150 DOI: 10.1016/j.jchf.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 06/07/2024]
Affiliation(s)
- David A Baran
- Section of Heart Failure, Transplant and Mechanical Circulatory Support, Heart Vascular and Thoracic Institute, Cleveland Clinic-Florida, Weston, Florida, USA.
| | - David Snipelisky
- Section of Heart Failure, Transplant and Mechanical Circulatory Support, Heart Vascular and Thoracic Institute, Cleveland Clinic-Florida, Weston, Florida, USA
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10
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Driscoll A, Clayden S, Lowe G. Call for the development and use of nurse practitioner sensitive outcome measures. Eur J Cardiovasc Nurs 2024; 23:e37-e38. [PMID: 38306407 DOI: 10.1093/eurjcn/zvae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 02/04/2024]
Affiliation(s)
- Andrea Driscoll
- School of Nursing and Midwifery, Deakin University, 1 Gheringhap Street, Geelong, VIC 3220, Australia
| | - Suzie Clayden
- Deakin Rural Health, Deakin University, Warrnambool, VIC 3280, Australia
| | - Grainne Lowe
- School of Nursing, Federation University, 72-100 Clyde Road, Berwick, VIC 3806, Australia
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11
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Chang TW, Hung CL, Ko SL, Liao CT, Hsu CY, Huang N, Mebazaa A, Chang HY. Bridging the STRONG Gap: Call to Optimize Heart Failure Treatment After Hospitalization in Women and Men in Taiwan. Am J Cardiol 2024; 223:52-57. [PMID: 38763384 DOI: 10.1016/j.amjcard.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/30/2024] [Accepted: 05/11/2024] [Indexed: 05/21/2024]
Abstract
The benefits of rapidly up-titrating evidence-based treatments following heart failure (HF) hospitalizations were demonstrated in the The Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies (STRONG-HF) trial and emphasized in contemporary HF guidelines. We aimed to assess up-titration patterns of guideline-directed medical treatments in the Taiwanese HF population. Combining data from the Taiwan Society of Cardiology - Heart Failure with reduced Ejection Fraction (TSOC-HFrEF) registry and the Treatment with Angiotensin Receptor neprilysin inhibitor for Taiwan Acute Heart Failure (TAROT-AHF) study cohort, we formed the "Taiwan real-world cohort". We compared these data with subgroups of patients with left ventricular ejection fraction ≤40% in the STRONG-HF trial. Patients in the Taiwan cohort exhibited similar blood pressure, heart rate and N-terminal pro B-type natriuretic peptide levels at discharge compared with those in the STRONG-HF trial. A higher proportion of patients in the STRONG-HF high-intensity care group received up-titrations compared with those in the usual care group and the Taiwan cohort. Composite all-cause mortality or HF hospitalization at 180 days for patients in the high-intensity care group, usual care group, and Taiwan cohort were 17.4%, 23.7%, and 31.9%, respectively, with differences largely contributed by HF hospitalization (10.1%, 17.9%, and 27.6%, respectively), whereas all-cause mortality rates were similar (11.0%, 9.6%, and 9.3%, respectively). Gender did not affect this trend. In conclusion, our data highlights a treatment gap between the STRONG-HF trial and real-world practices in Taiwan, urging prompt optimization of HF therapy.
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Affiliation(s)
- Tao-Wei Chang
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chung-Lieh Hung
- Institute of Biomedical Sciences, Mackay Medical College, New Taipei City, Taiwan; Division of Cardiology, Departments of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shao-Lun Ko
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Te Liao
- Division of Cardiology, Chi-Mei Medical Center, Tainan, Taiwan
| | - Chien-Yi Hsu
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine; Department of Medicine Research, Taipei Medical University Hospital, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine; Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France.
| | - Hung-Yu Chang
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Hospital and Health Care Administration, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan.
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12
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Ambrosy AP, Chang AJ, Davison B, Voors A, Cohen-Solal A, Damasceno A, Kimmoun A, Lam CSP, Edwards C, Tomasoni D, Gayat E, Filippatos G, Saidu H, Biegus J, Celutkiene J, Ter Maaten JM, Čerlinskaitė-Bajorė K, Sliwa K, Takagi K, Metra M, Novosadova M, Barros M, Adamo M, Pagnesi M, Arrigo M, Chioncel O, Diaz R, Pang PS, Ponikowski P, Cotter G, Mebazaa A. Titration of Medications After Acute Heart Failure Is Safe, Tolerated, and Effective Regardless of Risk. JACC. HEART FAILURE 2024:S2213-1779(24)00337-8. [PMID: 38739123 DOI: 10.1016/j.jchf.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Guideline-directed medical therapy (GDMT) decisions may be less affected by single patient variables such as blood pressure or kidney function and more by overall risk profile. In STRONG-HF (Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure), high-intensity care (HIC) in the form of rapid uptitration of heart failure (HF) GDMT was effective overall, but the safety, tolerability and efficacy of HIC across the spectrum of HF severity is unknown. Evaluating this with a simple risk-based framework offers an alternative and more clinically translatable approach than traditional subgroup analyses. OBJECTIVES The authors sought to assess safety, tolerability, and efficacy of HIC according to the simple, powerful, and clinically translatable MAGGIC (Meta-Analysis Global Group in Chronic) HF risk score. METHODS In STRONG-HF, 1,078 patients with acute HF were randomized to HIC (uptitration of treatments to 100% of recommended doses within 2 weeks of discharge and 4 scheduled outpatient visits over the 2 months after discharge) vs usual care (UC). The primary endpoint was the composite of all-cause death or first HF rehospitalization at day 180. Baseline HF risk profile was determined by the previously validated MAGGIC risk score. Treatment effect was stratified according to MAGGIC risk score both as a categorical and continuous variable. RESULTS Among 1,062 patients (98.5%) with complete data for whom a MAGGIC score could be calculated at baseline, GDMT use at baseline was similar across MAGGIC tertiles. Overall GDMT prescriptions achieved for individual medication classes were higher in the HIC vs UC group and did not differ by MAGGIC risk score tertiles (interaction nonsignificant). The incidence of all-cause death or HF readmission at day 180 was, respectively, 16.3%, 18.9%, and 23.2% for MAGGIC risk score tertiles 1, 2, and 3. The HIC arm was at lower risk of all-cause death or HF readmission at day 180 (HR: 0.66; 95% CI: 0.50-0.86) and this finding was robust across MAGGIC risk score modeled as a categorical (HR: 0.51; 95% CI: 0.62-0.68 in tertiles 1, 2, and 3; interaction nonsignificant) for all comparisons and continuous (interaction nonsignificant) variable. The rate of adverse events was higher in the HIC group, but this observation did not differ based on MAGGIC risk score tertile (interaction nonsignificant). CONCLUSIONS HIC led to better use of GDMT and lower HF-related morbidity and mortality compared with UC, regardless of the underlying HF risk profile. (Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP testinG, of Heart Failure Therapies [STRONG-HF]; NCT03412201).
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Affiliation(s)
- Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA; Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.
| | - Alex J Chang
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Momentum Research Inc, Durham, North Carolina, USA; Heart Initiative, Durham, North Carolina, USA
| | - Adriaan Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France
| | | | - Antoine Kimmoun
- Université de Lorraine, Nancy, INSERM, Défaillance Circulatoire Aigue et Chronique, Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandoeuvre-lès-Nancy, France
| | - Carolyn S P Lam
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands; National Heart Centre Singapore and Duke-National University of Singapore
| | | | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Etienne Gayat
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital/Bayero University Kano, Kano, Nigeria
| | - Jan Biegus
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Kamilė Čerlinskaitė-Bajorė
- Cape Heart Institute, Department of Medicine and Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Karen Sliwa
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland
| | - Koji Takagi
- Momentum Research Inc, Durham, North Carolina, USA
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | | | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Mattia Arrigo
- Emergency Institute for Cardiovascular Diseases "Prof. C.C.Iliescu," University of Medicine "Carol Davila," Bucharest, Romania
| | - Ovidiu Chioncel
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Rafael Diaz
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Momentum Research Inc, Durham, North Carolina, USA; Heart Initiative, Durham, North Carolina, USA
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
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13
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Asano T, Maeno Y, Nakano M, Taguri M, Miyasaka M, Nakai D, Miyazaki I, Nasu T, Tanimoto S, Masuda N, Morino Y, Isshiki T, Ogata N. Validation of a New Scoring Method to Assess the Efficacy of Rapid Initiation and Titration of Combination Pharmacotherapy for Patients Hospitalized with Acute Decompensated Heart Failure with Reduced and Mildly Reduced Ejection Fraction. J Clin Med 2024; 13:2775. [PMID: 38792317 PMCID: PMC11122539 DOI: 10.3390/jcm13102775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/28/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Despite the encouragement of early initiation and titration of guideline-directed medical therapy (GDMT) for the treatment of heart failure (HF), most patients do not receive an adequate type and dose of pharmacotherapy in the real world. Objectives: This study aimed to determine the efficacy of titrating composite GDMT in patients with HF with reduced and mildly reduced ejection fraction and to identify patient conditions that may benefit from titration of GDMT. Methods: This was a two-center, retrospective study of consecutive patients hospitalized with acute decompensated heart failure (ADHF). Patients were classified into two groups according to a scoring scale determined by combination and doses of four types of HF agents (ACEis/ARBs/ARNis, BBs, MRAs, and SGLT2is) at discharge. A score of 5 or greater was defined as titrated GDMT, and a score of 4 or less was regarded as sub-optimal medical therapy (MT). Results: A total of 979 ADHF patients were screened. After 553 patients were excluded based on exclusion criteria, 426 patients (90 patients in the titrated GDMT group and 336 patients in the sub-optimal MT group) were enrolled for the analysis. The median follow-up period was 612 (453-798) days. Following statistical adjustment using the propensity score weighting method, the 2-year composite endpoint (composite of cardiac death and HF rehospitalization) rate was significantly lower in the titrated GDMT group, at 19%, compared with the sub-optimal MT group: 31% (score 3-4 points) and 43% (score 0-2 points). Subgroup analysis indicated a marked benefit of titrated GDMT in particular patient subgroups: age < 80 years, BMI 19.0-24.9, eGFR > 20 mL/min/1.73 m2, and serum potassium level ≤ 5.5 mmol/L. Conclusions: Prompt initiation and dose adjustment of multiple HF medications, with careful monitoring of the patient's physiologic and laboratory values, is a prerequisite for improving the prognosis of patients with heart failure.
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Affiliation(s)
- Takaaki Asano
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun 028-3694, Japan; (T.A.)
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Yoshio Maeno
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Masataka Nakano
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Masataka Taguri
- Department of Health Data Science, Tokyo Medical University, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Masaki Miyasaka
- Department of Cardiology, Jikei University, Minato-ku, Tokyo 105-0003, Japan
| | - Daisuke Nakai
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Itaru Miyazaki
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Takahito Nasu
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun 028-3694, Japan; (T.A.)
| | - Shuzou Tanimoto
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Naoki Masuda
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun 028-3694, Japan; (T.A.)
| | - Takaaki Isshiki
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Nobuhiko Ogata
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
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14
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Breathett K, Lewsey S, Brownell NK, Enright K, Evangelista LS, Ibrahim NE, Iturrizaga J, Matlock DD, Ogunniyi MO, Sterling MR, Van Spall HGC. Implementation Science to Achieve Equity in Heart Failure Care: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e1143-e1163. [PMID: 38567497 DOI: 10.1161/cir.0000000000001231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Guideline-directed medical therapies and guideline-directed nonpharmacological therapies improve quality of life and survival in patients with heart failure (HF), but eligible patients, particularly women and individuals from underrepresented racial and ethnic groups, are often not treated with these therapies. Implementation science uses evidence-based theories and frameworks to identify strategies that facilitate uptake of evidence to improve health. In this scientific statement, we provide an overview of implementation trials in HF, assess their use of conceptual frameworks and health equity principles, and provide pragmatic guidance for equity in HF. Overall, behavioral nudges, multidisciplinary care, and digital health strategies increased uptake of therapies in HF effectively but did not include equity goals. Few HF studies focused on achieving equity in HF by engaging stakeholders, quantifying barriers and facilitators to HF therapies, developing strategies for equity informed by theory or frameworks, evaluating implementation measures for equity, and titrating strategies for equity. Among these HF equity studies, feasibility was established in using various educational strategies to promote organizational change and equitable care. A couple include ongoing randomized controlled pragmatic trials for HF equity. There is great need for additional HF implementation trials designed to promote delivery of equitable guideline-directed therapy.
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15
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Khan MS, Chan PS, Sherrod CF, Ikemura N, Sauer AJ, Jones PG, Fonarow GC, Butler J, DeVore AD, Lund LH, Spertus JA. Generalizable Approach to Quantifying Guideline-Directed Medical Therapy. Circ Heart Fail 2024; 17:e011164. [PMID: 38742418 PMCID: PMC11108743 DOI: 10.1161/circheartfailure.123.011164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/30/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Quantifying guideline-directed medical therapy (GDMT) intensity is foundational for improving heart failure (HF) care. Existing measures discount dose intensity or use inconsistent weighting. METHODS The Kansas City Medical Optimization (KCMO) score is the average of total daily to target dose percentages for eligible GDMT, reflecting the percentage of optimal GDMT prescribed (range, 0-100). In Change the Management of Patients With HF, we computed KCMO, HF collaboratory (0-7), and modified HF Collaboratory (0-100) scores for each patient at baseline and for 1-year change in established GDMT at the time (mineralocorticoid receptor antagonist, β-blocker, ACE [angiotensin-converting enzyme] inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor). We compared baseline and 1-year change distributions and the coefficient of variation (SD/mean) across scores. RESULTS Among 4532 patients at baseline, mean KCMO, HF collaboratory, and modified HF Collaboratory scores were 38.8 (SD, 25.7), 3.4 (1.7), and 42.2 (22.2), respectively. The mean 1-year change (n=4061) for KCMO was -1.94 (17.8); HF collaborator, -0.11 (1.32); and modified HF Collaboratory, -1.35 (19.8). KCMO had the highest coefficient of variation (0.66), indicating greater variability around the mean than the HF collaboratory (0.49) and modified HF Collaboratory (0.53) scores, reflecting higher resolution of the variability in GDMT intensity across patients. CONCLUSIONS KCMO measures GDMT intensity by incorporating dosing and treatment eligibility, provides more granularity than existing methods, is easily interpretable (percentage of ideal GDMT), and can be adapted as performance measures evolve. Further study of its association with outcomes and its usefulness for quality assessment and improvement is needed.
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Affiliation(s)
- Mirza S. Khan
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Paul S. Chan
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Charles F. Sherrod
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Nobuhiro Ikemura
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Andrew J. Sauer
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Philip G. Jones
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Gregg C. Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Adam D. DeVore
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Lars H. Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - John A. Spertus
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
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16
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Rivas-Lasarte M, Ferreira JP. Heart Failure in Brazil and the Need to Measure and Take Action. J Card Fail 2024; 30:651-652. [PMID: 38016621 DOI: 10.1016/j.cardfail.2023.10.485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 10/25/2023] [Indexed: 11/30/2023]
Affiliation(s)
- Mercedes Rivas-Lasarte
- Cardiology Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain.
| | - João Pedro Ferreira
- Cardiovascular Research and Development Center, Department of Surgery and Physiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal, and Université de Lorraine, Nancy, France
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17
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Stamerra CA, Di Giosia P, Giorgini P, Jamialahmadi T, Sahebkar A. Cardiovascular Effects of Stimulators of Soluble Guanylate Cyclase Administration: A Meta-analysis of Randomized Controlled Trials. Curr Atheroscler Rep 2024; 26:177-187. [PMID: 38564140 DOI: 10.1007/s11883-024-01197-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW Heart failure (HF) is one of the main causes of cardiovascular mortality in the western world. Despite great advances in treatment, recurrence and mortality rates remain high. Soluble guanylate cyclase is an enzyme which, by producing cGMP, is responsible for the effects of vasodilation, reduction of cardiac pre- and after-load and, therefore, the improvement of myocardial performance. Thus, a new therapeutic strategy is represented by the stimulators of soluble guanylate cyclase (sGCs). The aim of this meta-analysis was to analyze the effects deriving from the administration of sGCs, in subjects affected by HF. A systematic literature search of Medline, SCOPUS, and Google Scholar was conducted up to December 2022 to identify RCTs assessing the cardiovascular effects, as NT-pro-BNP values and ejection fraction (EF), and all-cause mortality, of the sGCs. Quantitative data synthesis was performed using a random-effects model, with weighted mean difference (WMD) and 95% confidence interval (CI) as summary statistics. RECENT FINDINGS The results obtained documented a statistically significant improvement in NT-proBNP values (SMD: - 0.258; 95% CI: - 0.398, - 0.118; p < 0.001) and EF (WMD: 0.948; 95% CI: 0.485, 1.411; p < 0.001) in subjects treated with sGCs; however, no significant change was found in the all-cause mortality rate (RR 0.96; 95% CI 0.868 to 1.072; I2, p = 0). The sGCs represent a valid therapeutic option in subjects suffering from HF, leading to an improvement in cardiac performance.
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Affiliation(s)
| | - Paolo Di Giosia
- Department of Internal Medicine-Mazzoni Hospital, Ascoli Piceno, Italy
| | - Paolo Giorgini
- Department of Emergency-Madonna del Soccorso Hospital, San Benedetto del Tronto, Italy
| | - Tannaz Jamialahmadi
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Medical Toxicology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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18
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Zhang Z, Wang C, Tu T, Lin Q, Zhou J, Huang Y, Wu K, Zhang Z, Zuo W, Liu N, Xiao Y, Liu Q. Advancing Guideline-Directed Medical Therapy in Heart Failure: Overcoming Challenges and Maximizing Benefits. Am J Cardiovasc Drugs 2024; 24:329-342. [PMID: 38568400 PMCID: PMC11093832 DOI: 10.1007/s40256-024-00646-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 05/15/2024]
Abstract
The delayed titration of guideline-directed drug therapy (GDMT) is a complex event influenced by multiple factors that often result in poor prognosis for patients with heart failure (HF). Individualized adjustments in GDMT titration may be necessary based on patient characteristics, and every clinician is responsible for promptly initiating GDMT and titrating it appropriately within the patient's tolerance range. This review examines the current challenges in GDMT implementation and scrutinizes titration considerations within distinct subsets of HF patients, with the overarching goal of enhancing the adoption and effectiveness of GDMT. The authors also underscore the significance of establishing a novel management strategy that integrates cardiologists, nurse practitioners, pharmacists, and patients as a unified team that can contribute to the improved promotion and implementation of GDMT.
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Affiliation(s)
- Zixi Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Cancan Wang
- Department of Metabolic Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Tao Tu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Qiuzhen Lin
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Jiabao Zhou
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Yunying Huang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Keke Wu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Zeying Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Wanyun Zuo
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Na Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China.
| | - Qiming Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China.
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19
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Ostrominski JW, DeFilippis EM, Bansal K, Riello RJ, Bozkurt B, Heidenreich PA, Vaduganathan M. Contemporary American and European Guidelines for Heart Failure Management: JACC: Heart Failure Guideline Comparison. JACC. HEART FAILURE 2024; 12:810-825. [PMID: 38583167 DOI: 10.1016/j.jchf.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 04/09/2024]
Abstract
This review serves to compare contemporary clinical practice recommendations for the management of heart failure (HF), as codified in the 2021 European Society of Cardiology (ESC) guideline, the 2022 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) guideline, and the 2023 focused update of the 2021 ESC document. Overall, these guidelines aim to solidify significant advances throughout the HF continuum since the publication of previous full guideline iterations (2013 and 2016 for the ACC/AHA and ESC, respectively). All guidelines provide new recommendations for an increasingly complex landscape of HF care, with focus on primary HF prevention, HF stages, rapid initiation and optimization of evidence-based pharmacotherapies, overlapping cardiac and noncardiac comorbidities, device-based therapies, and management pathways for special groups of patients, including those with cardiac amyloidosis. Importantly, the ACC/AHA/HFSA document features special emphasis on HF risk prediction and screening, cost/value, social determinants of health, and health care disparities. The review discusses major similarities and differences between these recent guidelines and guideline updates, as well as their potential downstream implications for clinical care.
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Affiliation(s)
- John W Ostrominski
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Kannu Bansal
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Ralph J Riello
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut, USA
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiovascular Research Institute, Baylor College of Medicine and DeBakey VA Medical Center, Houston, Texas, USA
| | - Paul A Heidenreich
- Department of Medicine, VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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20
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Bismpos D, Wintrich J, Hövelmann J, Böhm M. Latest pharmaceutical approaches across the spectrum of heart failure. Heart Fail Rev 2024; 29:675-687. [PMID: 38349462 PMCID: PMC11035443 DOI: 10.1007/s10741-024-10389-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Abstract
Despite major advances in prevention and medical therapy, heart failure (HF) remains associated with high morbidity and mortality, especially in older and frailer patients. Therefore, a complete, guideline-based treatment is essential, even in HF patients with conditions traditionally associated with a problematic initiation and escalation of the medical HF therapy, such as chronic kidney disease and arterial hypotension, as the potential adverse effects are overcome by the overall decrease of the absolute risk. Furthermore, since the latest data suggest that the benefit of a combined medical therapy (MRA, ARNI, SGLT2i, beta-blocker) may extend up to a LVEF of 65%, further trials on these subgroups of patients (HFmrEF, HFpEF) are needed to re-evaluate the guideline-directed medical therapy across the HF spectrum. In particular, the use of SGLT2i was recently extended to HFpEF patients, as evidenced by the DELIVER and EMPEROR-preserved trials. Moreover, the indication for other conservative treatments in HF patients, such as the intravenous iron supplementation, was accordingly strengthened in the latest guidelines. Finally, the possible implementation of newer substances, such as finerenone, in guideline-directed medical practice for HF is anticipated with great interest.
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Affiliation(s)
- Dimitrios Bismpos
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany.
- Department of Internal Medicine II, Cardiology and Angiology, Marien Hospital Herne, University Clinic of the Ruhr University, Bochum University, Herne, Germany.
| | - Jan Wintrich
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Julian Hövelmann
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
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21
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Kokorin VA, González-Franco A, Cittadini A, Kalejs O, Larina VN, Marra AM, Medrano FJ, Monhart Z, Morbidoni L, Pimenta J, Lesniak W. Acute heart failure - an EFIM guideline critical appraisal and adaptation for internists. Eur J Intern Med 2024; 123:4-14. [PMID: 38453571 DOI: 10.1016/j.ejim.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 02/26/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Over the past two decades, several studies have been conducted that have tried to answer questions on management of patients with acute heart failure (AHF) in terms of diagnosis and treatment. Updated international clinical practice guidelines (CPGs) have endorsed the findings of these studies. The aim of this document was to adapt recommendations of existing guidelines to help internists make decisions about specific and complex scenarios related to AHF. METHODS The adaptation procedure was to identify firstly unresolved clinical problems in patients with AHF in accordance with the PICO (Population, Intervention, Comparison and Outcomes) process, then conduct a critical assessment of existing CPGs and choose recommendations that are most applicable to these specific scenarios. RESULTS Seven PICOs were identified and CPGs were assessed. There is no single test that can help clinicians in discriminating patients with acute dyspnoea, congestion or hypoxaemia. Performing of echocardiography and natriuretic peptide evaluation is recommended, and chest X-ray and lung ultrasound may be considered. Treatment strategies to manage arterial hypotension and low cardiac output include short-term continuous intravenous inotropic support, vasopressors, renal replacement therapy, and temporary mechanical circulatory support. The most updated recommendations on how to treat specific patients with AHF and certain comorbidities and for reducing post-discharge rehospitalization and mortality are provided. Overall, 51 recommendations were endorsed and the rationale for the selection is provided in the main text. CONCLUSION Through the use of appropriate tailoring process methodology, this document provides a simple and updated guide for internists dealing with AHF patients.
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Affiliation(s)
- Valentin A Kokorin
- Department of Hospital Therapy named after academician P.E. Lukomsky, Pirogov Russian National Research Medical University, Department of Hospital Therapy with courses in Endocrinology, Hematology and Clinical Laboratory Diagnostics, Peoples' Friendship University of Russia named after Patrice Lumumba, Moscow, Russia
| | - Alvaro González-Franco
- Internal Medicine Unit, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Antonio Cittadini
- Department of Translational Medical Sciences, "Federico II" University Hospital and school of medicine, Naples, Italy
| | - Oskars Kalejs
- Department of Internal Medicine, Riga Stradins University, Latvian Center of Cardiology, P. Stradins Clinical University hospital, Riga, Latvia
| | - Vera N Larina
- Department of Polyclinic Therapy, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Alberto M Marra
- Department of Translational Medical Sciences, "Federico II" University Hospital and school of medicine, Naples, Italy; Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Francisco J Medrano
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla), CIBERESP and Department of Medicine, Universidad de Sevilla, Seville, Spain.
| | - Zdenek Monhart
- Internal Medicine Department, Znojmo Hospital, Znojmo; Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Laura Morbidoni
- Internal Medicine Unit "Principe di Piemonte" Hospital Senigallia (AN), Italy
| | - Joana Pimenta
- Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Cardiovascular R&D Centre-UnIC@RISE, Faculdade de Medicina da Universidade do Porto, Portugal
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22
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Sindone AP, Driscoll A, Audehm R, Sverdlov AL, McVeigh J, Alicia Chan WP, Hickey A, Hopper I, Chang T, Maiorana A, Atherton JJ. Optimising Transitional Care Following a Heart Failure Hospitalisation in Australia. Heart Lung Circ 2024:S1443-9506(24)00193-8. [PMID: 38692982 DOI: 10.1016/j.hlc.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 11/18/2023] [Accepted: 11/26/2023] [Indexed: 05/03/2024]
Abstract
Hospitalisations for heart failure (HF) are associated with high rates of readmission and death, the most vulnerable period being within the first few weeks post-hospital discharge. Effective transition of care from hospital to community settings for patients with HF can help reduce readmission and mortality over the vulnerable period, and improve long-term outcomes for patients, their family or carers, and the healthcare system. Planning and communication underpin a seamless transition of care, by ensuring that the changes to patients' management initiated in hospital continue to be implemented following discharge and in the long term. This evidence-based guide, developed by a multidisciplinary group of Australian experts in HF, discusses best practice for achieving appropriate and effective transition of patients hospitalised with HF to community care in the Australian setting. It provides guidance on key factors to address before and after hospital discharge, as well as practical tools that can be used to facilitate a smooth transition of care.
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Affiliation(s)
- Andrew P Sindone
- Heart Failure Unit and Department of Cardiology, Concord Hospital, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia.
| | - Andrea Driscoll
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; School of Nursing and Midwifery, Centre for Quality and Patient Safety, Faculty of Health, Deakin University, Geelong, Vic, Australia
| | - Ralph Audehm
- Department of General Practice and Primary Health Care, The University of Melbourne, Melbourne, Vic, Australia
| | - Aaron L Sverdlov
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia; Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia; Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - James McVeigh
- Heart Failure Service, The Prince of Wales Hospital, Randwick, NSW, Australia
| | | | | | - Ingrid Hopper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology and General Medicine Unit, Alfred Health, Melbourne, Vic, Australia
| | - Tim Chang
- Fiona Stanley Hospital, Perth, WA, Australia
| | - Andrew Maiorana
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia; Allied Health Department and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Perth, WA, Australia
| | - John J Atherton
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia; Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia; Faculty of Science, Health, Education and Engineering, University of Sunshine Coast, Sunshine Coast, Qld, Australia; Faculty of Health, Queensland University of Technology, Brisbane, Qld, Australia
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23
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Preda A, Montecucco F, Carbone F, Camici GG, Lüscher TF, Kraler S, Liberale L. SGLT2 inhibitors: from glucose-lowering to cardiovascular benefits. Cardiovasc Res 2024; 120:443-460. [PMID: 38456601 DOI: 10.1093/cvr/cvae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
An increasing number of individuals are at high risk of type 2 diabetes (T2D) and its cardiovascular complications, including heart failure (HF), chronic kidney disease (CKD), and eventually premature death. The sodium-glucose co-transporter-2 (SGLT2) protein sits in the proximal tubule of human nephrons to regulate glucose reabsorption and its inhibition by gliflozins represents the cornerstone of contemporary T2D and HF management. Herein, we aim to provide an updated overview of the pleiotropy of gliflozins, provide mechanistic insights and delineate related cardiovascular (CV) benefits. By discussing contemporary evidence obtained in preclinical models and landmark randomized controlled trials, we move from bench to bedside across the broad spectrum of cardio- and cerebrovascular diseases. With landmark randomized controlled trials confirming a reduction in major adverse CV events (MACE; composite endpoint of CV death, non-fatal myocardial infarction, and non-fatal stroke), SGLT2 inhibitors strongly mitigate the risk for heart failure hospitalization in diabetics and non-diabetics alike while conferring renoprotection in specific patient populations. Along four major pathophysiological axes (i.e. at systemic, vascular, cardiac, and renal levels), we provide insights into the key mechanisms that may underlie their beneficial effects, including gliflozins' role in the modulation of inflammation, oxidative stress, cellular energy metabolism, and housekeeping mechanisms. We also discuss how this drug class controls hyperglycaemia, ketogenesis, natriuresis, and hyperuricaemia, collectively contributing to their pleiotropic effects. Finally, evolving data in the setting of cerebrovascular diseases and arrhythmias are presented and potential implications for future research and clinical practice are comprehensively reviewed.
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Affiliation(s)
- Alberto Preda
- Department of Clinical Cardiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Royal Brompton and Harefield Hospitals and Imperial College and King's College, London, United Kingdom
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Internal Medicine, Cantonal Hospital Baden, Baden, Switzerland
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
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24
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Mocan D, Lala RI, Puschita M, Pilat L, Darabantiu DA, Pop-Moldovan A. The Congestion "Pandemic" in Acute Heart Failure Patients. Biomedicines 2024; 12:951. [PMID: 38790913 PMCID: PMC11117769 DOI: 10.3390/biomedicines12050951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/07/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024] Open
Abstract
Congestion not only represents a cardinal sign of heart failure (HF) but is also now recognized as the primary cause of hospital admissions, rehospitalization, and mortality among patients with acute heart failure (AHF). Congestion can manifest through various HF phenotypes in acute settings: volume overload, volume redistribution, or both. Recognizing the congestion phenotype is paramount, as it implies different therapeutic strategies for decongestion. Among patients with AHF, achieving complete decongestion is challenging, as more than half still experience residual congestion at discharge. Residual congestion is one of the strongest predictors of future cardiovascular events and poor outcomes. Through this review, we try to provide a better understanding of the congestion phenomenon among patients with AHF by highlighting insights into the pathophysiological mechanisms behind congestion and new diagnostic and management tools to achieve and maintain efficient decongestion.
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Affiliation(s)
- Daniela Mocan
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | - Radu Ioan Lala
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
- Cardiology Department, Arad County Clinical Emergency Hospital, 310037 Arad, Romania
| | - Maria Puschita
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | - Luminita Pilat
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | | | - Adina Pop-Moldovan
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
- Cardiology Department, Arad County Clinical Emergency Hospital, 310037 Arad, Romania
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25
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Asada K, Saito Y, Goto H, Yaginuma H, Sato T, Hashimoto O, Kitahara H, Kobayashi Y. Differential Prognostic Impact of Risk-Prediction Models for Heart Failure in Acute Myocardial Infarction: The Original and Revised Heart Failure Time-Points. J Clin Med 2024; 13:2501. [PMID: 38731029 PMCID: PMC11084542 DOI: 10.3390/jcm13092501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Background: We previously developed a risk-scoring system for heart failure (HF) in patients with acute myocardial infarction (MI), namely "HF time-points (HFTPs)". In the original HFTPs, the presence of HF on admission, during hospitalization, and at short-term follow-up was individually scored. This study examined whether the revised HFTPs, with additional scoring of previous HF, provide better predictivity. Methods: This multicenter registry included a total of 1331 patients with acute MI undergoing percutaneous coronary intervention. HF was evaluated at four time-points before and after acute MI onset: (1) a history of HF; (2) elevated natriuretic peptide levels on admission; (3) in-hospital HF events; and (4) elevated natriuretic peptide levels at a median of 31 days after the onset. When HF was present at each time-point, one point was assigned to a risk scoring system, namely the original and revised HFTPs, ranging from 0 to 3 and from 0 to 4. The primary endpoint was a composite of cardiovascular death and HF rehospitalization after discharge. Results: Of the 1331 patients, 65 (4.9%) had the primary outcome events during a median follow-up period of 507 (interquartile range, 335-1106) days. The increase in both original and revised HFTPs was associated with an increased risk of the primary outcomes in a stepwise fashion with similar diagnostic ability. Conclusions: The original and revised HFTPs were both predictive of long-term HF-related outcomes in patients with acute MI undergoing percutaneous coronary intervention. Yet, the original HFTPs may be sufficient to estimate HF risks after MI.
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Affiliation(s)
- Kazunari Asada
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan; (K.A.); (H.G.); (H.Y.); (T.S.); (H.K.); (Y.K.)
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan; (K.A.); (H.G.); (H.Y.); (T.S.); (H.K.); (Y.K.)
| | - Hiroki Goto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan; (K.A.); (H.G.); (H.Y.); (T.S.); (H.K.); (Y.K.)
| | - Hiroaki Yaginuma
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan; (K.A.); (H.G.); (H.Y.); (T.S.); (H.K.); (Y.K.)
| | - Takanori Sato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan; (K.A.); (H.G.); (H.Y.); (T.S.); (H.K.); (Y.K.)
| | - Osamu Hashimoto
- Department of Cardiology, Chiba Emergency and Psychiatric Medical Center, Chiba 261-0024, Japan;
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan; (K.A.); (H.G.); (H.Y.); (T.S.); (H.K.); (Y.K.)
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan; (K.A.); (H.G.); (H.Y.); (T.S.); (H.K.); (Y.K.)
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26
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Crowe B, Misra S, Lee CD. Overcoming clinical inertia with SGLT-2 inhibitors: Strategies to accelerate adoption in heart failure. J Hosp Med 2024. [PMID: 38647371 DOI: 10.1002/jhm.13374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/25/2024] [Accepted: 04/10/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Byron Crowe
- Harvard Medical School, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Shantum Misra
- Harvard Medical School, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Clement D Lee
- Newton-Wellesley Hospital, Newton, Massachusetts, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
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27
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Basic C, Schaufelberger M. Peripartum cardiomyopathy: the challenge of predicting cardiac function recovery. Eur Heart J 2024; 45:1440-1442. [PMID: 38442138 DOI: 10.1093/eurheartj/ehae111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Affiliation(s)
- Carmen Basic
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine Geriatrics and Emergency Medicine, Sahlgrenska University Hospital/Östra Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Maria Schaufelberger
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine Geriatrics and Emergency Medicine, Sahlgrenska University Hospital/Östra Hospital, Region Västra Götaland, Gothenburg, Sweden
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28
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Okami S, Lecomte C, Raad H, Aguila M, Mohrova Z, Takeichi M, Tsuchiya T, Ohlmeier C, Evers T, Michel A. Initiation and continuation of pharmacological therapies in patients hospitalized for heart failure in Japan. Sci Rep 2024; 14:9095. [PMID: 38643208 PMCID: PMC11032365 DOI: 10.1038/s41598-024-60011-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/17/2024] [Indexed: 04/22/2024] Open
Abstract
Currently, the utilization patterns of medications for heart failure (HF) after worsening HF events remain unelucidated in Japan. Here, we conducted a retrospective cohort study evaluating the changes in HF drug utilization patterns in 6 months before and after hospitalizations for HF. The adherence to newly initiated HF medications was evaluated based on the proportion of days covered (PDC) and persistence as continuous treatment episodes among new users. The study included 9091 patients hospitalized for HF between January 2016 and September 2019, including 2735 (30.1%) patients who were newly prescribed at least one HF medication after hospitalization. Despite increases in the use of foundational HF therapy (beta-blockers, angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers, or mineralocorticoid receptor antagonists), 35.6% and 7.6% of patients were treated with the HF foundational monotherapy or diuretics alone after hospitalization, respectively. The mean PDC of newly initiated HF medications ranged from 0.57 for thiazide diuretics to 0.77 for sodium-glucose cotransporter-2 inhibitors. Continuous use of HF medications during the first year after initiation was observed in 30-60% of patients. The mean PDC and one-year continuous HF medication use were consistently lower in patients aged ≥ 75 years and in patients with a history of HF hospitalization for all HF medication classes except for tolvaptan and digoxin. Despite the guideline recommendations of HF pharmacotherapy, both treatment and adherence were suboptimal after HF hospitalization, especially in vulnerable populations such as older patients and those with prior HF hospitalizations.
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Affiliation(s)
- Suguru Okami
- Medical Affairs & Pharmacovigilance, Bayer Yakuhin Ltd., Breeze Tower, 2-4-9 Umeda, Kita-Ku, Osaka, 530-0001, Japan.
| | | | | | | | | | - Makiko Takeichi
- Medical Affairs & Pharmacovigilance, Bayer Yakuhin Ltd., Breeze Tower, 2-4-9 Umeda, Kita-Ku, Osaka, 530-0001, Japan
| | - Takanori Tsuchiya
- Market Access & Public Affairs, Bayer Yakuhin, Ltd, 2-4-9 Umeda, Kita-Ku, Osaka, Japan
| | - Christoph Ohlmeier
- Integrated Evidence Generation & Business Innovation, Bayer AG, 13342, Berlin, Germany
| | - Thomas Evers
- Integrated Evidence Generation & Business Innovation, Bayer AG, 42096, Wuppertal, Germany
| | - Alexander Michel
- Integrated Evidence Generation & Business Innovation, Bayer Consumer Care AG, Peter Merian Straße 84, 4052, Basel, Switzerland
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Neuen BL, Tuttle KR, Vaduganathan M. Accelerated Risk-Based Implementation of Guideline-Directed Medical Therapy for Type 2 Diabetes and Chronic Kidney Disease. Circulation 2024; 149:1238-1240. [PMID: 38620082 DOI: 10.1161/circulationaha.123.068524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Affiliation(s)
- Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N.)
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia (B.L.N.)
- Division of Cardiovascular Medicine, Center for Cardiometabolic Implementation Science, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.L.N., M.V.)
| | - Katherine R Tuttle
- University of Washington and Providence Medical Research Center, Providence Health Care, Spokane (K.R.T.)
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Center for Cardiometabolic Implementation Science, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.L.N., M.V.)
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Maddox TM, Januzzi JL, Allen LA, Breathett K, Brouse S, Butler J, Davis LL, Fonarow GC, Ibrahim NE, Lindenfeld J, Masoudi FA, Motiwala SR, Oliveros E, Walsh MN, Wasserman A, Yancy CW, Youmans QR. 2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2024; 83:1444-1488. [PMID: 38466244 DOI: 10.1016/j.jacc.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
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Moon J, Udell JA, Chong A, Fang J, Austin PC, Ko DT, Stukel TA, Atzema CL, Booth GL, Tu K, Naimark DMJ, Jackevicius CA. Time to SGLT2 Inhibitors Initiation in Patients With Heart Failure. J Am Heart Assoc 2024; 13:e032296. [PMID: 38563368 DOI: 10.1161/jaha.123.032296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/28/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Jungyeon Moon
- College of Pharmacy Western University of Health Sciences Pomona CA USA
| | - Jacob A Udell
- Cardiovascular Division, Department of Medicine Women's College Hospital and Peter Munk Cardiac Centre, Toronto General Hospital Toronto Ontario Canada
- University of Toronto Toronto Ontario Canada
- ICES Toronto Ontario Canada
| | | | | | - Peter C Austin
- University of Toronto Toronto Ontario Canada
- ICES Toronto Ontario Canada
| | - Dennis T Ko
- University of Toronto Toronto Ontario Canada
- ICES Toronto Ontario Canada
- Schulich Heart Centre Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Therese A Stukel
- University of Toronto Toronto Ontario Canada
- ICES Toronto Ontario Canada
| | - Clare L Atzema
- University of Toronto Toronto Ontario Canada
- ICES Toronto Ontario Canada
- Division of Emergency Medicine, Department of Medicine Sunnybrook Health Sciences Center Toronto Ontario Canada
| | - Gillian L Booth
- University of Toronto Toronto Ontario Canada
- ICES Toronto Ontario Canada
- MAP Centre for Urban Health Solutions Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto Ontario Canada
| | - Karen Tu
- University of Toronto Toronto Ontario Canada
- Division of Emergency Medicine, Department of Medicine Sunnybrook Health Sciences Center Toronto Ontario Canada
- North York General Hospital Toronto Ontario Canada
- Toronto Western Hospital Family Health Team Network Toronto Ontario Canada
| | - David M J Naimark
- University of Toronto Toronto Ontario Canada
- ICES Toronto Ontario Canada
- Division of Nephrology, Department of Medicine Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Cynthia A Jackevicius
- College of Pharmacy Western University of Health Sciences Pomona CA USA
- University of Toronto Toronto Ontario Canada
- ICES Toronto Ontario Canada
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles CA USA
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32
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Harikrishnan S, Rath PC, Bang V, McDonagh T, Ogola E, Silva H, Rajbanshi BG, Pathirana A, Ng GA, Biga C, Lüscher TF, Daggubati R, Adivi S, Roy D, Banerjee PS, Das MK. Heart failure, the global pandemic: A call to action consensus statement from the global presidential conclave at the platinum jubilee conference of cardiological society of India 2023. Indian Heart J 2024:S0019-4832(24)00057-9. [PMID: 38609052 DOI: 10.1016/j.ihj.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 03/26/2024] [Accepted: 04/08/2024] [Indexed: 04/14/2024] Open
Abstract
Heart failure (HF) is emerging as a major public health problem both in high- and low - income countries. The mortality and morbidity due to HF is substantially higher in low-middle income countries (LMICs). Accessibility, availability and affordability issues affect the guideline directed therapy implementation in HF care in those countries. This call to action urges all those concerned to initiate preventive strategies as early as possible, so that we can reduce HF-related morbidity and mortality. The most important step is to have better prevention and treatment strategies for diseases such as hypertension, ischemic heart disease (IHD), type-2 diabetes, and rheumatic heart disease (RHD) which predispose to the development of HF. Setting up dedicated HF-clinics manned by HF Nurses, can help in streamlining HF care. Subsidized in-patient care, financial assistance for device therapy, use of generic medicines (including polypill strategy) will be helpful, along with the use of digital technologies.
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Affiliation(s)
| | - Prathap Chandra Rath
- Apollo Health City, Jubilee Hills, Hyderabad, President, Cardiological Society of India (CSI), India
| | - Vijay Bang
- Lilavati Hospital, Bandra West, Mumbai, Immediate Past-President, CSI, India
| | | | - Elijah Ogola
- University of Nairobi (Kenya), President Pan African Society of Cardiology, Kenya
| | - Hugo Silva
- Hospital General de Agudos Dr. Cosme Argerich, Buenos Aires, Treasurer, Argentinian Cardiac Society, Argentina
| | - Bijoy G Rajbanshi
- Nepal Mediciti, Lalitpur, Past-President, Cardiac Society of Nepal, Nepal
| | - Anidu Pathirana
- National Hospital of SriLanka, Past-President SriLanka Heart Association, Sri Lanka
| | - G Andre Ng
- University of Leicester, President-Elect, British Cardiovascular Society, United Kingdom
| | - Cathleen Biga
- President and CEO of Cardiovascular Management of Illinois, Vice President, American College of Cardiology, USA
| | - Thomas F Lüscher
- Royal Brompton Hospital Imperial College London, London, President-Elect European Society of Cardiology, United Kingdom
| | - Ramesh Daggubati
- West Virginia University School of Medicine, Morgantown, WV, USA
| | - Shirley Adivi
- West Virginia University School of Medicine, Morgantown, WV, USA
| | - Debabrata Roy
- Rabindranath Tagore Institute of Cardiac Sciences, Kolkata, Hon. General Secretary, CSI, India
| | - P S Banerjee
- Manipal Hospital, Kolkata, Past-President, CSI, India
| | - M K Das
- B.M. Birla Heart Research Centre, Kolkata, Past-President CSI, India
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de Oliveira MT, Baptista R, Chavez-Leal SA, Bonatto MG. Heart failure management with β-blockers: can we do better? Curr Med Res Opin 2024; 40:43-54. [PMID: 38597068 DOI: 10.1080/03007995.2024.2318002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/08/2024] [Indexed: 04/11/2024]
Abstract
Heart failure (HF) is associated with disabling symptoms, poor quality of life, and a poor prognosis with substantial excess mortality in the years following diagnosis. Overactivation of the sympathetic nervous system is a key feature of the pathophysiology of HF and is an important driver of the process of adverse remodelling of the left ventricular wall that contributes to cardiac failure. Drugs which suppress the activity of the renin-angiotensin-aldosterone system, including β-blockers, are foundation therapies for the management of heart failure with reduced ejection fraction (HFrEF) and despite a lack of specific outcomes trials, are also widely used by cardiologist in patients with HF with preserved ejection fraction (HFpEF). Today, expert opinion has moved away from recommending that treatment for HF should be guided solely by the LVEF and interventions should rather address signs and symptoms of HF (e.g. oedema and tachycardia), the severity of HF, and concomitant conditions. β-blockers improve HF symptoms and functional status in HF and these agents have demonstrated improved survival, as well as a reduced risk of other important clinical outcomes such as hospitalisation for heart failure, in randomised, placebo-controlled outcomes trials. In HFpEF, β-blockers are anti-ischemic and lower blood pressure and heart rate. Moreover, β-blockers also reduce mortality in the setting of HF occurring alongside common comorbid conditions, such as diabetes, CKD (of any severity), and COPD. Higher doses of β-blockers are associated with better clinical outcomes in populations with HF, so that ensuring adequate titration of therapy to their maximal (or maximally tolerated) doses is important for ensuring optimal outcomes for people with HF. In principle, a patient with HF could have combined treatment with a β-blocker, renin-angiotensin-aldosterone system inhibitor/neprilysin inhibitor, mineralocorticoid receptor antagonist, and a SGLT2 inhibitor, according to tolerability.
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Affiliation(s)
- Mucio Tavares de Oliveira
- Heart Institute, Day Hospital and Infusion Center, University of Sao Paulo Medical School, Sao Paulo, Brazil
- Infusion Center and Day Hospital at Heart Institute (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Rui Baptista
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- Cardiology Department, Centro Hospitalar Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | | | - Marcely Gimenes Bonatto
- Department of Heart Failure and Heart Transplant, Hospital Santa Casa de Misericórdia de, Curitiba, Brazil
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Parrini I, Lucà F, Rao CM, Cacciatore S, Riccio C, Grimaldi M, Gulizia MM, Oliva F, Andreotti F. How to Manage Beta-Blockade in Older Heart Failure Patients: A Scoping Review. J Clin Med 2024; 13:2119. [PMID: 38610883 PMCID: PMC11012494 DOI: 10.3390/jcm13072119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/22/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
Beta blockers (BBs) play a crucial role in enhancing the quality of life and extending the survival of patients with heart failure and reduced ejection fraction (HFrEF). Initiating the therapy at low doses and gradually titrating the dose upwards is recommended to ensure therapeutic efficacy while mitigating potential adverse effects. Vigilant monitoring for signs of drug intolerance is necessary, with dose adjustments as required. The management of older HF patients requires a case-centered approach, taking into account individual comorbidities, functional status, and frailty. Older adults, however, are often underrepresented in randomized clinical trials, leading to some uncertainty in management strategies as patients with HF in clinical practice are older than those enrolled in trials. The present article performs a scoping review of the past 25 years of published literature on BBs in older HF patients, focusing on age, outcomes, and tolerability. Twelve studies (eight randomized-controlled and four observational) encompassing 26,426 patients were reviewed. The results indicate that BBs represent a viable treatment for older HFrEF patients, offering benefits in symptom management, cardiac function, and overall outcomes. Their role in HF with preserved EF, however, remains uncertain. Further research is warranted to refine treatment strategies and address specific aspects in older adults, including proper dosing, therapeutic adherence, and tolerability.
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Affiliation(s)
- Iris Parrini
- Department of Cardiology, Mauriziano Hospital, Largo Filippo Turati, 62, 10128 Turin, Italy;
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Via Melacrino 1, 89124 Reggio Calabria, Italy;
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Via Melacrino 1, 89124 Reggio Calabria, Italy;
| | - Stefano Cacciatore
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, Via Ferdinando Palasciano, 81100 Caserta, Italy;
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
| | | | - Fabrizio Oliva
- “A. De Gasperis” Cardiovascular Department, Division of Cardiology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy;
| | - Felicita Andreotti
- Cardiovascular and Respiratory Sciences, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy;
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35
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Van den Eynde J, Verbrugge FH. Renal Sodium Avidity in Heart Failure. Cardiorenal Med 2024; 14:270-280. [PMID: 38565080 DOI: 10.1159/000538601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/22/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Increased renal sodium avidity is a hallmark feature of the heart failure syndrome. SUMMARY Increased renal sodium avidity refers to the inability of the kidneys to elicit potent natriuresis in response to sodium loading. This eventually causes congestion, which is a major contributor to hospital admissions and mortality in heart failure. KEY MESSAGES Important novel concepts such as the renal tamponade hypothesis, accelerated nephron loss, and the role of hypochloremia, the sympathetic nervous system, inflammation, the lymphatic system, and interstitial sodium buffers are involved in the pathophysiology of renal sodium avidity. A good understanding of these concepts is crucially important with respect to treatment recommendations regarding dietary sodium restriction, fluid restriction, rapid up-titration of guideline-directed medical therapies, combination diuretic therapy, natriuresis-guided diuretic therapy, use of hypertonic saline, and ultrafiltration.
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Affiliation(s)
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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36
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Kapelios CJ, Lund LH. Preemptive Versus Urgent Heart Failure Hospitalization as a Surrogate for Mortality Risk in Heart Failure. Circulation 2024; 149:1062-1064. [PMID: 38557123 DOI: 10.1161/circulationaha.123.068066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- Chris J Kapelios
- Heart Failure and Transplant Unit, Onassis Cardiac Surgery Center, Athens, Greece (C.J.K.)
| | - Lars H Lund
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden (L.H.L.)
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37
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Comments on the 2023 update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:281-284. [PMID: 38048844 DOI: 10.1016/j.rec.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 12/06/2023]
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Brahmbhatt DH, Ross HJ, O'Sullivan M, Artanian V, Mueller B, Runeckles K, Steve Fan CP, Rac VE, Seto E. The Effect of Using a Remote Patient Management Platform in Optimizing Guideline-Directed Medical Therapy in Heart Failure Patients: A Randomized Controlled Trial. JACC. HEART FAILURE 2024; 12:678-690. [PMID: 38569821 DOI: 10.1016/j.jchf.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/23/2024] [Accepted: 02/06/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Guideline-directed medical therapy (GDMT) remains underutilized in patients with heart failure with reduced ejection fraction, leading to morbidity and mortality. OBJECTIVES The Medly Titrate (Use of Telemonitoring to Facilitate Heart Failure Mediation Titration) study was an open-label, randomized controlled trial to determine whether remote medication titration for patients with heart failure with reduced ejection fraction was more effective than usual care (UC). METHODS In this study, 108 patients were randomized to remote GDMT titration through the Medly heart failure program (n = 56) vs UC (n = 52). The primary outcome was the proportion of patients completing GDMT titration at 6 months. Secondary outcomes included the number of clinic visits and time required to achieve titration, patient health outcomes, and health care utilization, including urgent clinic/emergency department visits and hospitalization. RESULTS At 6 months, GDMT titration was completed in 82.1% (95% CI: 71.2%-90.8%) of patients in the intervention arm vs 53.8% in UC (95% CI: 41.1%-67.7%; P = 0.001). Remote titration required fewer in-person (1.62 ± 1.09 vs 2.42 ± 1.65; P = 0.004) and virtual clinic visits (0.50 ± 1.08 vs 1.29 ± 1.86; P = 0.009) to complete titration. Median time to optimization was shorter with remote titration (3.42 months [Q1-Q3: 2.99-4.04 months] vs 5.47 months [Q1-Q3: 4.14-7.33 months]; P < 0.001). The number of urgent clinic/emergency department visits (incidence rate ratio of remote vs control groups: 0.90 [95% CI: 0.53-1.56]; P = 0.70) were similar between groups, with a reduction in all-cause hospitalization with remote titration (incidence rate ratio: 0.55 [95% CI: 0.31-0.97]; P = 0.042). CONCLUSIONS Remote titration of GDMT in heart failure with reduced ejection fraction was effective, safe, feasible, and increased the proportion of patients achieving target doses, in a shorter period of time with no excess adverse events compared with UC. (Use of Telemonitoring to Facilitate Heart Failure Mediation Titration [Medly Titrate]; NCT04205513).
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Affiliation(s)
- Darshan H Brahmbhatt
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Heather J Ross
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Mary O'Sullivan
- Centre for Digital Therapeutics, University Health Network, Toronto, Ontario, Canada
| | - Veronica Artanian
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Brigitte Mueller
- Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Kyle Runeckles
- Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Valeria E Rac
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Program for Health System and Technology Evaluation, University Health Network, Toronto, Ontario, Canada
| | - Emily Seto
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Centre for Digital Therapeutics, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
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Tang AB, Brownell NK, Roberts JS, Haidar A, Osuna-Garcia A, Cho DJ, Bokhoor P, Fonarow GC. Interventions for Optimization of Guideline-Directed Medical Therapy: A Systematic Review. JAMA Cardiol 2024; 9:397-404. [PMID: 38381449 DOI: 10.1001/jamacardio.2023.5627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Importance Implementation of guideline-directed medical therapy (GDMT) in real-world practice remains suboptimal. It is unclear which interventions are most effective at addressing current barriers to GDMT in patients with heart failure with reduced ejection fraction (HFrEF). Objective To perform a systematic review to identify which types of system-level initiatives are most effective at improving GDMT use among patients with HFrEF. Evidence Review PubMed, Embase, Cochrane, CINAHL, and Web of Science databases were queried from January 2010 to November 2023 for randomized clinical trials that implemented a quality improvement intervention with GDMT use as a primary or secondary outcome. References from related review articles were also included for screening. Quality of studies and bias assessment were graded based on the Cochrane Risk of Bias tool and Oxford Centre for Evidence-Based Medicine. Findings Twenty-eight randomized clinical trials were included with an aggregate sample size of 19 840 patients. Studies were broadly categorized as interdisciplinary interventions (n = 15), clinician education (n = 5), electronic health record initiatives (n = 6), or patient education (n = 2). Overall, interdisciplinary titration clinics were associated with significant increases in the proportion of patients on target doses of GDMT with a 10% to 60% and 2% to 53% greater proportion of patients on target doses of β-blockers and renin-angiotensin-aldosterone system inhibitors, respectively, in intervention groups compared with usual care. Other interventions, such as audits, clinician and patient education, or electronic health record alerts, were also associated with some improvements in GDMT utilization, though these findings were inconsistent across studies. Conclusions and Relevance This review summarizes interventions aimed at optimization of GDMT in clinical practice. Initiatives that used interdisciplinary teams, largely comprised of nurses and pharmacists, most consistently led to improvements in GDMT. Additional large, randomized studies are necessary to better understand other types of interventions, as well as their long-term efficacy and sustainability.
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Affiliation(s)
- Amber B Tang
- Department of Medicine, University of California Los Angeles
| | - Nicholas K Brownell
- Department of Medicine, Division of Cardiology, University of California Los Angeles
| | - Jacob S Roberts
- Department of Medicine, University of California Los Angeles
| | - Amier Haidar
- Department of Medicine, University of California Los Angeles
| | - Antonia Osuna-Garcia
- Louise M. Darling Biomedical Library, UCLA Library, University of California Los Angeles
| | - David J Cho
- Department of Medicine, Division of Cardiology, University of California Los Angeles
| | - Pooya Bokhoor
- Department of Medicine, Division of Cardiology, University of California Los Angeles
| | - Gregg C Fonarow
- Department of Medicine, Division of Cardiology, University of California Los Angeles
- Associate Section Editor, JAMA Cardiology
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Reza N. High-Intensity Care Versus GDMT Titration: Which Rapidly Improves Health Status in Patients With Heart Failure? Circ Heart Fail 2024; 17:e011627. [PMID: 38445961 PMCID: PMC11021140 DOI: 10.1161/circheartfailure.124.011627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/05/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Tomasoni D, Davison B, Adamo M, Pagnesi M, Mebazaa A, Edwards C, Arrigo M, Barros M, Biegus J, Čelutkienė J, Čerlinskaitė-Bajorė K, Chioncel O, Cohen-Solal A, Damasceno A, Diaz R, Filippatos G, Gayat E, Kimmoun A, Lam CSP, Novosadova M, Pang PS, Ponikowski P, Saidu H, Sliwa K, Takagi K, Maaten JMT, Voors A, Cotter G, Metra M. Safety Indicators in Patients Receiving High-intensity Care After Hospital Admission for Acute Heart Failure: The STRONG-HF Trial. J Card Fail 2024; 30:525-537. [PMID: 37820896 DOI: 10.1016/j.cardfail.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies (STRONG-HF) demonstrated the safety and efficacy of rapid up-titration of guideline-directed medical therapy (GDMT) with high-intensity care (HIC) compared with usual care in patients hospitalized for acute heart failure (HF). In the HIC group, the following safety indicators were used to guide up-titration: estimated glomerular filtration rate of <30 mL/min/1.73 m2, serum potassium of >5.0 mmol/L, systolic blood pressure (SBP) of <95 mmHg, heart rate of <55 bpm, and N-terminal pro-B-type natriuretic peptide concentration of >10% higher than predischarge values. METHODS AND RESULTS We examined the impact of protocol-specified safety indicators on achieved dose of GDMT and clinical outcomes. Three hundred thirteen of the 542 patients in the HIC arm (57.7%) met ≥1 safety indicator at any follow-up visit 1-6 weeks after discharge. As compared with those without, patients meeting ≥1 safety indicator had more severe HF symptoms, lower SBP, and higher heart rate at baseline and achieved a lower average percentage of GDMT optimal doses (mean difference vs the HIC arm patients not reaching any safety indicator, -11.0% [95% confidence interval [CI] -13.6 to -8.4%], P < .001). The primary end point of 180-day all-cause death or HF readmission occurred in 15.0% of patients with any safety indicator vs 14.2% of those without (adjusted hazard ratio 0.84, 95% CI 0.48-1.46, P = .540). None of each of the safety indicators, considered alone, was significantly associated with the primary end point, but an SBP of <95 mm Hg was associated with a trend toward increased 180-day all-cause mortality (adjusted hazard ratio 2.68, 95% CI 0.94-7.64, P = .065) and estimated glomerular filtration rate decreased to <30 mL/min/1.73 m2 with more HF readmissions (adjusted hazard ratio 3.60, 95% CI 1.22-10.60, P = .0203). The occurrence of a safety indicator was associated with a smaller 90-day improvement in the EURO-QoL 5-Dimension visual analog scale (adjusted mean difference -3.32 points, 95% CI -5.97 to -0.66, P = .015). CONCLUSIONS Among patients with acute HF enrolled in STRONG-HF in the HIC arm, the occurrence of any safety indicator was associated with the administration of slightly lower GDMT doses and less improvement in quality of life, but with no significant increase in the primary outcome of 180-day HF readmission or death when appropriately addressed according to the study protocol.
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Affiliation(s)
- Daniela Tomasoni
- Depaetment of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Momentum Research Inc, Durham, North Carolina; Heart Initiative, Durham, North Carolina
| | - Marianna Adamo
- Depaetment of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Depaetment of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
| | | | - Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland
| | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof. C.C. Iliescu", University of Medicine "Carol Davila", Bucharest, Romania
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; AP-HP Nord, Department of Cardiology, Lariboisière University Hospital, Paris, France
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Etienne Gayat
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
| | - Antoine Kimmoun
- Université de Lorraine, Nancy; INSERM, Défaillance Circulatoire Aigue et Chronique; Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandœuvre-lès-Nancy, Francel
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore; Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | | | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital, Bayero University Kano, Kano, Nigeria
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine and Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Koji Takagi
- Momentum Research Inc, Durham, North Carolina
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Adriaan Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Momentum Research Inc, Durham, North Carolina; Heart Initiative, Durham, North Carolina
| | - Marco Metra
- Depaetment of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
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Scoma CB, Lee DH, Money D, Eichelberger G, Usmani A, Cohen AJ, Fernandez J. The Impact of Midodrine on Guideline-Directed Medical Therapy in Patients Admitted With Systolic Heart Failure. J Cardiovasc Pharmacol 2024; 83:353-358. [PMID: 38127885 DOI: 10.1097/fjc.0000000000001532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 12/03/2023] [Indexed: 12/23/2023]
Abstract
ABSTRACT Midodrine is occasionally used off-label to treat hypotension associated with advanced heart failure (HF); however, its association with changes in prescription of guideline-directed medical therapy (GDMT) is unknown. We sought to evaluate the effect of midodrine on the GDMT prescription pattern and clinical outcomes of patients with decompensated systolic HF. We retrospectively identified 114 patients admitted to our hospital in 2020 with decompensated systolic HF who were prescribed midodrine on discharge and compared them with 358 patients with decompensated systolic HF who were not prescribed midodrine. At 6 months, the midodrine group had more initiation or up-titration of beta blockers, renin-angiotensin-aldosterone system inhibitors, and sodium-glucose cotransporter-2 inhibitors compared with the nonmidodrine group. Survival at 6 months was similar between the 2 groups, but the midodrine group had more frequent rehospitalization for HF. Our findings suggest that midodrine is associated with improved GDMT in patients with decompensated HF but may be associated with worse prognosis.
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Affiliation(s)
- Christopher B Scoma
- Division of Cardiovascular Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Dae Hyun Lee
- Division of Cardiovascular Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - David Money
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL; and
| | - Gerry Eichelberger
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL; and
| | - Ahsan Usmani
- Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Adam J Cohen
- Division of Cardiovascular Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Joel Fernandez
- Division of Cardiovascular Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL
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Marques P, Sharma A, Ferreira JP. Is Reducing Heart Failure Hospitalization Associated With Reducing Mortality in Heart Failure Trials? JACC. HEART FAILURE 2024; 12:779-784. [PMID: 38456853 DOI: 10.1016/j.jchf.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Pedro Marques
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Cardiovascular Research and Development Center, Porto, Portugal; Department of Internal Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal; Division of Cardiology, DREAM-CV Lab, McGill University Health Centre, Montreal, Quebec, Canada
| | - Abhinav Sharma
- Division of Cardiology, DREAM-CV Lab, McGill University Health Centre, Montreal, Quebec, Canada.
| | - João Pedro Ferreira
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Cardiovascular Research and Development Center, Porto, Portugal; Heart Failure Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal; Institut National de la Santé et de la Recherche Médicale U1116, Centre Hospitalier Régional Universitaire, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
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Tomasoni D, Cannatà A, Adamo M, Metra M. 2023 focused update of the 2021 ESC heart failure guidelines: Key messages for clinical practice. Eur J Clin Invest 2024; 54:e14163. [PMID: 38235824 DOI: 10.1111/eci.14163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/01/2023] [Indexed: 01/19/2024]
Affiliation(s)
- Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Cannatà
- King's College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, UK
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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45
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Rossello X. Safety Indicators in the STRONG-HF Trial From a Methodological Perspective. J Card Fail 2024; 30:538-540. [PMID: 38395380 DOI: 10.1016/j.cardfail.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Xavier Rossello
- Cardiology Department, Hospital Universitari Son Espases, Palma, Spain; Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain; Facultad de Medicina, Universitat de les Illes Balears (UIB), Palma, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
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Čelutkienė J, Čerlinskaitė-Bajorė K, Cotter G, Edwards C, Adamo M, Arrigo M, Barros M, Biegus J, Chioncel O, Cohen-Solal A, Damasceno A, Diaz R, Filippatos G, Gayat E, Kimmoun A, Léopold V, Metra M, Novosadova M, Pagnesi M, Pang PS, Ponikowski P, Saidu H, Sliwa K, Takagi K, Ter Maaten JM, Tomasoni D, Lam CSP, Voors AA, Mebazaa A, Davison B. Impact of Rapid Up-Titration of Guideline-Directed Medical Therapies on Quality of Life: Insights From the STRONG-HF Trial. Circ Heart Fail 2024; 17:e011221. [PMID: 38445950 DOI: 10.1161/circheartfailure.123.011221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND This analysis provides details on baseline and changes in quality of life (QoL) and its components as measured by EQ-5D-5L questionnaire, as well as association with objective outcomes, applying high-intensity heart failure (HF) care in patients with acute HF. METHODS In STRONG-HF trial (Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies) patients with acute HF were randomized just before discharge to either usual care or a high-intensity care strategy of guideline-directed medical therapy up-titration. Patients ranked their state of health on the EQ-5D visual analog scale score ranging from 0 (the worst imaginable health) to 100 (the best imaginable health) at baseline and at 90 days follow-up. RESULTS In 1072 patients with acute HF with available assessment of QoL (539/533 patients assigned high-intensity care/usual care) the mean baseline EQ-visual analog scale score was 59.2 (SD, 15.1) with no difference between the treatment groups. Patients with lower baseline EQ-visual analog scale (meaning worse QoL) were more likely to be women, self-reported Black and non-European (P<0.001). The strongest independent predictors of a greater improvement in QoL were younger age (P<0.001), no HF hospitalization in the previous year (P<0.001), lower NYHA class before hospital admission (P<0.001) and high-intensity care treatment (mean difference, 4.2 [95% CI, 2.5-5.8]; P<0.001). No statistically significant heterogeneity in the benefits of high-intensity care was seen across patient subgroups of different ages, with left ventricular ejection fraction above or below 40%, NT-proBNP (N-terminal pro-B-type natriuretic peptide) and systolic blood pressure above or below the median value. The treatment effect on the primary end point did not vary significantly across baseline EQ-visual analog scale (Pinteraction=0.87). CONCLUSIONS Early up-titration of guideline-directed medical therapy significantly improves all dimensions of QoL in patients with HF and improves prognosis regardless of baseline self-assessed health status. The likelihood of achieving optimal doses of HF medications does not depend on baseline QoL. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03412201.
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Affiliation(s)
- Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), France (G.C., A.C.-S., E.G., V.L., A.M., B.D.)
- Heart Initiative, Durham, NC (G.C., B.D.)
- Momentum Research, Inc, Durham, NC. (G.C., C.E., M.B., M.N., K.T., B.D.)
| | | | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M. Adamo, M.M., M.P., D.T.)
| | - Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Switzerland (M. Arrigo)
| | - Marianela Barros
- Momentum Research, Inc, Durham, NC. (G.C., C.E., M.B., M.N., K.T., B.D.)
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Poland (J.B., P.P.)
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof. C.C.Iliescu," University of Medicine "Carol Davila," Bucharest, Romania (O.C.)
| | - Alain Cohen-Solal
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
- Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France (A.C.-S.)
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Argentina (R.D.)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Greece (G.F.)
| | - Etienne Gayat
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France (E.G., V.L., A.M.)
| | - Antoine Kimmoun
- Université de Lorraine, Nancy; INSERM, Défaillance Circulatoire Aigue et Chronique; Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, France (A.K.)
| | - Valentine Léopold
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France (E.G., V.L., A.M.)
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M. Adamo, M.M., M.P., D.T.)
| | - Maria Novosadova
- Momentum Research, Inc, Durham, NC. (G.C., C.E., M.B., M.N., K.T., B.D.)
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M. Adamo, M.M., M.P., D.T.)
| | - Peter S Pang
- Departments of Emergency Medicine and Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.)
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Poland (J.B., P.P.)
| | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital/Bayero University Kano, Nigeria (H.S.)
| | - Karen Sliwa
- Cape Heart Institute, Division of Cardiology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (K.S.)
| | - Koji Takagi
- Momentum Research, Inc, Durham, NC. (G.C., C.E., M.B., M.N., K.T., B.D.)
| | - Jozine M Ter Maaten
- Department of Cardiology, Medical Centre Groningen, the Netherlands (J.M.T.M., A.A.V.)
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M. Adamo, M.M., M.P., D.T.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.)
- Baim Institute for Clinical Research, Boston, MA (C.S.P.L.)
- University Medical Centre Groningen, the Netherlands (C.S.P.L.)
| | - Adriaan A Voors
- Department of Cardiology, Medical Centre Groningen, the Netherlands (J.M.T.M., A.A.V.)
| | - Alexandre Mebazaa
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France (E.G., V.L., A.M.)
| | - Beth Davison
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
- Heart Initiative, Durham, NC (G.C., B.D.)
- Momentum Research, Inc, Durham, NC. (G.C., C.E., M.B., M.N., K.T., B.D.)
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Zafeiropoulos S, Farmakis IT, Milioglou I, Doundoulakis I, Gorodeski EZ, Konstantinides SV, Cooper L, Zanos S, Stavrakis S, Giamouzis G, Butler J, Giannakoulas G. Pharmacological Treatments in Heart Failure With Mildly Reduced and Preserved Ejection Fraction: Systematic Review and Network Meta-Analysis. JACC. HEART FAILURE 2024; 12:616-627. [PMID: 37656079 DOI: 10.1016/j.jchf.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Medical treatment for heart failure with preserved ejection (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF) has weaker evidence compared with reduced ejection fraction, despite recent trials with an angiotensin receptor neprilysin inhibitor (ARNI) and sodium glucose co-transporter 2 inhibitors (SGLT2is). OBJECTIVES The authors aimed to estimate the aggregate therapeutic benefit of drugs for HFmrEF and HFpEF. METHODS The authors performed a systematic review of MEDLINE, CENTRAL, and Web of Science for randomized trials including patients with heart failure (HF) and left ventricular ejection fraction (LVEF) >40%, treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (analyzed together as renin-angiotensin system inhibitors [RASi]), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), digoxin, ARNI, and SGLT2i. An additive component network meta-analysis was performed. The primary outcome was a composite of cardiovascular (CV) death and first hospitalization for heart failure (HHF); secondary outcomes were CV death, total HHF, and all-cause mortality. RESULTS The authors identified 13 studies with a total of 29,875 patients and a mean LVEF of 56.3% ± 8.7%. ARNI, MRA, and SGLT2i separately, but not RASi, BB, or digoxin, reduced the primary composite outcome compared with placebo. The combination of ARNI, BB, MRA, and SGLT2i was the most effective (HR: 0.47 [95% CI: 0.31-0.70]); this was largely explained by the triple combination of ARNI, MRA, and SGLT2i (HR: 0.56 [95% CI 0.43-0.71]). Results were similar for CV death (HR: 0.63 [95% CI 0.43-0.91] for ARNI, MRA, and SGLT2i) or total HHF (HR: 0.49 [95% CI 0.33-0.71] for ARNI, MRA, and SGLT2i) alone. In a subgroup analysis, only SGLT2i had a consistent benefit among all LVEF subgroups, whereas the triple combination had the greatest benefit in HFmrEF, robust benefit in patients with LVEF 50% to 59%, and a statistically marginal benefit in patients with LVEF ≥60%. CONCLUSIONS In patients with HF and LVEF>40%, the quadruple combination of ARNI, BB, MRA, and SGLT2i provides the largest reduction in the risk of CV death and HHF; driven by the robust effect of the triple combination of ARNI, MRA, and SGLT2i. The benefit was more pronounced in HFmrEF patients.
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Affiliation(s)
- Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, New York, USA; Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Germany; Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece
| | - Ioannis Milioglou
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio, USA
| | - Ioannis Doundoulakis
- Athens Heart Center, Athens Medical Center, Athens, Greece; First Department of Cardiology, National and Kapodistrian University, "Hippokration" Hospital, Athens, Greece
| | - Eiran Z Gorodeski
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio, USA
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupoli, Greece
| | - Lauren Cooper
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA; Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA
| | - Stavros Zanos
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Grigorios Giamouzis
- Department of Cardiology, University of Thessaly, Larissa, Greece; Faculty of Medicine, School of Health Sciences, University of Thessaly, Greece
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
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Johansen ND, Vaduganathan M, Bhatt AS, Lee SG, Modin D, Claggett BL, Dueger EL, Samson S, Loiacono MM, Harris RC, Køber L, Solomon SD, Sivapalan P, Jensen JUS, Martel CJM, Krause TG, Biering-Sørensen T. Clinical Outcomes With Electronic Nudges to Increase Influenza Vaccination : A Prespecified Analysis of a Nationwide, Pragmatic, Registry-Based, Randomized Implementation Trial. Ann Intern Med 2024; 177:476-483. [PMID: 38498876 DOI: 10.7326/m23-2638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND In the NUDGE-FLU (Nationwide Utilization of Danish Government Electronic letter system for increasing inFLUenza vaccine uptake) trial, electronic letters incorporating cardiovascular (CV) gain-framing and repeated messaging increased influenza vaccination by approximately 1 percentage point. OBJECTIVE To evaluate the effects of the successful nudging interventions on downstream clinical outcomes. DESIGN Prespecified exploratory analysis of a nationwide randomized implementation trial. (ClinicalTrials.gov: NCT05542004). SETTING The 2022 to 2023 influenza season. PARTICIPANTS 964 870 Danish citizens aged 65 years or older. INTERVENTION Usual care or 9 different electronically delivered behavioral nudging letters. MEASUREMENTS Cardiovascular, respiratory, and other clinical end points during follow-up from intervention delivery (16 September 2022) through 31 May 2023. RESULTS The analysis set included 691 820 participants. Hospitalization for pneumonia or influenza occurred in 3354 of 346 327 (1.0%) participants in the usual care group, 396 of 38 586 (1.0%) in the CV gain-framing group (hazard ratio [HR], 1.06 [95% CI, 0.95 to 1.18]; versus usual care), and 403 of 38 231 (1.1%) in the repeated letter group (HR, 1.09 [CI, 0.98 to 1.21]; versus usual care). In the usual care group, 44 682 (12.9%) participants were hospitalized for any cause, compared with 5002 (13.0%) in the CV gain-framing group (HR, 1.00 [CI, 0.97 to 1.03]; versus usual care) and 4965 (13.0%) in the repeated letter group (HR, 1.01 [CI, 0.98 to 1.04]; versus usual care). A total of 6341 (1.8%) participants died in the usual care group, compared with 721 (1.9%) in the CV gain-framing group (HR, 1.02 [CI, 0.94 to 1.10]; versus usual care) and 646 (1.7%) in the repeated letter group (HR, 0.92 [CI, 0.85 to 1.00]; versus usual care). LIMITATION Prespecified but exploratory analysis, potential misclassification of events in routinely collected registry data, and results may not be generalizable to other health systems or countries with other racial compositions and/or cultural or societal norms. CONCLUSION In a prespecified exploratory analysis, modest increases in influenza vaccination rates seen with electronic nudges did not translate into observable improvements in clinical outcomes. Seasonal influenza vaccination should remain strongly recommended. PRIMARY FUNDING SOURCE Sanofi.
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Affiliation(s)
- Niklas Dyrby Johansen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, and Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (N.D.J., D.M., T.B.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, and Center for Cardiometabolic Implementation Science, Brigham and Women's Hospital, Boston, Massachusetts (M.V., S.G.L.)
| | - Ankeet S Bhatt
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, and Center for Cardiometabolic Implementation Science, Brigham and Women's Hospital, Boston, Massachusetts, and Kaiser Permanente San Francisco Medical Center and Division of Research, San Francisco, California (A.S.B.)
| | - Simin Gharib Lee
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, and Center for Cardiometabolic Implementation Science, Brigham and Women's Hospital, Boston, Massachusetts (M.V., S.G.L.)
| | - Daniel Modin
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, and Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (N.D.J., D.M., T.B.)
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (B.L.C., S.D.S.)
| | | | | | | | | | - Lars Køber
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, and Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark (L.K.)
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (B.L.C., S.D.S.)
| | - Pradeesh Sivapalan
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, and Respiratory Medicine Section, Department of Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark (P.S., J.U.S.J.)
| | - Jens Ulrik Stæhr Jensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, and Respiratory Medicine Section, Department of Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark (P.S., J.U.S.J.)
| | - Cyril Jean-Marie Martel
- Epidemiological Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark (C.J.-M.M., T.G.K.)
| | - Tyra Grove Krause
- Epidemiological Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark (C.J.-M.M., T.G.K.)
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, and Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (N.D.J., D.M., T.B.)
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Prasad P, Chandrashekar P, Golwala H, Macon CJ, Steiner J. Functional Mitral Regurgitation: Patient Selection and Optimization. Interv Cardiol Clin 2024; 13:167-182. [PMID: 38432760 DOI: 10.1016/j.iccl.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Functional mitral regurgitation appears commonly among all heart failure phenotypes and can affect symptom burden and degree of maladaptive remodeling. Transcatheter mitral valve edge-to-edge repair therapies recently became an important part of the routine heart failure armamentarium for carefully selected and medically optimized candidates. Patient selection is considering heart failure staging, relevant comorbidities, as well as anatomic criteria. Indications and device platforms are currently expanding.
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Affiliation(s)
- Pooja Prasad
- Division of Cardiology, University of California-San Francisco, 505 Parnassus Avenue, Suite M1182, Box 0124, San Francisco, CA 94143, USA
| | - Pranav Chandrashekar
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Harsh Golwala
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Conrad J Macon
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Johannes Steiner
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA.
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50
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Huang CW, Park JS, Liu ILA, Lee JS, Kohan S, Mefford M, Wu SS, Subject CC, Nguyen HQ, Lee MS. Effectiveness and safety of early treatment with spironolactone for new-onset acute heart failure. J Hosp Med 2024; 19:267-277. [PMID: 38415888 DOI: 10.1002/jhm.13317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND The effectiveness and safety of mineralocorticoid receptor antagonists (MRA) in acute heart failure (HF) is uncertain. We sought to describe the prescription of spironolactone during acute HF and whether early treatment is effective and safe in a real-world setting. METHODS We performed a retrospective cohort study of adult (≥18 years) nonpregnant patients hospitalized with new-onset HF with reduced ejection fraction (HFrEF, defined by ejection fraction ≤40%) within 15 Kaiser Permanente Southern California medical centers between 2016 and 2021. Early treatment was defined by spironolactone prescription at discharge. The primary effectiveness outcome was a composite of HF readmission or all-cause mortality at 180 days. Safety outcomes were hypotension and hyperkalemia at 90 days. RESULTS Among 2318 HFrEF patients, 368 (15.9%) were treated with spironolactone at discharge. After 1:2 propensity score matching, 354 early treatment and 708 delayed/no treatment patients were included in the analysis. The median age was 63 (IQR: 52-74) years; 61.6% were male, and 38.6% were White. By 90 days, ~20% had crossed over in the two groups. Early treatment was not associated with the composite outcome at 180 days (HR [95% CI]: 0.81 [0.56-1.17]), but a trend towards benefit by 365 days that did not reach statistical significance (0.78 [0.58-1.06]). Early treatment was also associated with hyperkalemia (subdistribution HR [95% CI]: 2.33 [1.30-4.18]) but not hypotension (0.93 [0.51-1.72]). CONCLUSIONS Early treatment with spironolactone at discharge for new-onset HFrEF in a real-world setting did not reduce the risk of HF readmission or mortality in the first year after discharge. The risk of hyperkalemia was increased.
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Affiliation(s)
- Cheng-Wei Huang
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Joon S Park
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - In-Lu Amy Liu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Janet S Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Siamak Kohan
- Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Mathew Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Stefanie S Wu
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Christopher C Subject
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Ming-Sum Lee
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
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